Measuring vulnerability to childhood cancer treatment delays in low-income and middle-income countries
Authors: Jennifer Geel, Katherine Eyal
Journal: The Lancet Global Health (2023)

Quantifying the effect of delays in accessing optimal care for childhood cancers is complex, and the extent of the negative effect of these delays can differ by cancer type.1Barr RD “Delays” in diagnosis: a misleading concept, yet providing opportunities for advancing clinical care.J Pediatr Hematol Oncol. 2014; 36: 169-172Crossref PubMed Scopus (30) Google Scholar The causes and effects of diagnostic delays have been extensively investigated, with conflicting conclusions.2Abdelkhalek E Sherief L Kamal N Soliman R Factors associated with delayed cancer diagnosis in Egyptian children.Clin Med Insights Pediatr. 2014; 8: 39-44Crossref PubMed Google Scholar, 3Chukwu BF Ezenwosu OU Ikefuna AN Emodi IJ Diagnostic delay in pediatric cancer in Enugu, Nigeria: a prospective study.Pediatr Hematol Oncol. 2015; 32: 164-171Crossref PubMed Scopus (31) Google Scholar Out of necessity, these studies often make use of incomplete datasets. Despite numerous studies showing the role of health-care systems in diagnostic delays, factors such as culture, beliefs, and consultation of traditional healers are commonly cited as reasons for delays in accessing treatment.4Dang-Tan T Franco EL Diagnosis delays in childhood cancer: a review.Cancer. 2007; 110: 703-713Crossref PubMed Scopus (179) Google Scholar Childhood cancer health-care practitioners also frequently attribute delays in accessing the health-care system to patients’ families when children present late with disease-specific symptoms. In The Lancet Global Health, Cesia Cotache-Condor and colleagues5Cotache-Condor C Kantety V Grimm A et al.Determinants of delayed childhood cancer care in low- and middle-income countries: a systematic review.Pediatr Blood Cancer. 2023; 70e30175Crossref PubMed Scopus (3) Google Scholar analysed a pooled sample of 39 636 participants from a systematic review to identify 43 determinants and 24 risk factors associated with delayed childhood cancer care, and to create a clear three delay framework (seeking, reaching, and receiving care). The authors rigorously examined the relative importance of the numerous determinants of diagnostic delays that significantly contribute to childhood cancer mortality. They used a step-wise approach to create an innovative composite vulnerability index providing strong evidence refuting these and other widely held assumptions about the relationship between and the determinants of diagnostic delay and patient outcomes.6Cotache-Condor C Rice HE Schroeder K et al.Delays in cancer care for children in low-income and middle-income countries: development of a composite vulnerability index.Lancet Global Health. 2023; 11: e505-e515Summary Full Text Full Text PDF Scopus (2) Google Scholar The authors then calculated a composite vulnerability index for low-income and middle-income countries and found the highest vulnerability to mortality in sub-Saharan African countries. An important contribution is the holistic nature of the index, including many factors not previously controlled for in mortality analyses. One unexpected finding is the high vulnerability index value observed in Nigeria, the country with the highest gross domestic product (GDP) in Africa, which challenges previously held assumptions regarding the relationship between country incomes and childhood cancer mortality. A second unexpected finding is the absence of a significant association between HIV prevalence and childhood mortality, which possibly reflects increased competence in managing children with both HIV and cancer, as well as increased access to antiretroviral therapy and supportive care. However, opportunities remain to further explore this relationship, by controlling not only for country income levels, but also GDP growth, or country inequality measured by the Gini coefficient. The simple regression analysis showed that early detection programmes and defined referral pathways are not associated with decreased childhood cancer mortality. Although significant associations were shown between childhood cancer mortality and numbers of hospital beds per capita, external beam radiotherapy units, nuclear medicine physicians, pathology services, and transplantation services in the simple regression model, the factors that were significant in the multiple regression analysis were demographic indicators such as life expectancy, maternal education, and out-of-pocket fraction of health-care expenditure. The lack of significant association between numbers of trained medical personnel and mortality in the multiple linear regression shows that, while important, the availability of these resources should not be an automatic top priority of policy makers seeking to reduce childhood cancer mortality. The move to expand universal health coverage7World BankUHC in Africa: a framework for action.https://documents1.worldbank.org/curated/en/735071472096342073/pdf/108008-v1-REVISED-PUBLIC-Main-report-TICAD-UHC-Framework-FINAL.pdfDate accessed: February 7, 2023Google Scholar is not supported by Cotache-Condor and colleagues’ findings,5Cotache-Condor C Kantety V Grimm A et al.Determinants of delayed childhood cancer care in low- and middle-income countries: a systematic review.Pediatr Blood Cancer. 2023; 70e30175Crossref PubMed Scopus (3) Google Scholar but universal health coverage is an ill-defined concept. The majority of services required to treat childhood cancer might be provided under universal health coverage in one country, for example Canada, but only a small number of cancers might be covered in Ghana, for example, and yet both aim to provide universal health coverage.8Ngwa W Addai BW Adewole I et al.Cancer in sub-Saharan Africa: a Lancet Oncology Commission.Lancet Oncol. 2022; 23: e251-e312Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar Cotache-Condor and colleagues’ findings5Cotache-Condor C Kantety V Grimm A et al.Determinants of delayed childhood cancer care in low- and middle-income countries: a systematic review.Pediatr Blood Cancer. 2023; 70e30175Crossref PubMed Scopus (3) Google Scholar rely heavily on publicly available data, which are neither consistently available, nor guaranteed to be high quality across the globe. Datasets from low-resource settings are often incomplete and might not capture socioeconomic indicators, which are clearly shown here to be important. Clinician-researchers are strongly encouraged to make data from their studies publicly available for inclusion in future analyses. By working closely with biostatisticians, epidemiologists, and public health experts, relevant trends could be observed through interdisciplinary work. Cotache-Condor and colleagues’ paper5Cotache-Condor C Kantety V Grimm A et al.Determinants of delayed childhood cancer care in low- and middle-income countries: a systematic review.Pediatr Blood Cancer. 2023; 70e30175Crossref PubMed Scopus (3) Google Scholar removes much of the responsibility for improving services from health-care personnel, and places it firmly in the hands of policy makers and governments. Focusing on maternal education and out-of-pocket fraction of total health expenditure is the responsibility of government and will improve far more than just childhood cancer survival rates. Relevant ministries might use the composite vulnerability index as a baseline from which to measure improvement in their countries. The index aligns with the WHO Global Initiative for Childhood Cancer CureAll framework,9WHOCureAll framework: WHO global initiative for childhood cancer: increasing access, advancing quality, saving lives.https://apps.who.int/iris/handle/10665/347370Date accessed: August 12, 2022Google Scholar which has been enthusiastically adopted by various clinician-researchers in low-income and middle-income countries. Clinician-researchers have needed a way to communicate their findings to policy makers in a way that results in substantive change at a macro level. Using Cotache-Condor and colleagues’ composite vulnerability index could fundamentally improve such communication through its substantial contribution to the evidence base and help to dispel common misperceptions regarding causes and effects of diagnostic delays. JG reports a position as Secretary-General of International Paediatric Oncology Society Africa. KE declares no competing interests. Delays in cancer care for children in low-income and middle-income countries: development of a composite vulnerability indexOur composite vulnerability index can potentially serve as a valuable policy decision tool to help monitor country performance and guide interventions to reduce delays in care for children with cancer in LMICs. Full-Text PDF Open Access